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I've just seen a 74 YO lady, referred by her GP for a "proper foot support". She has a lifelong history of general foot pain and more recently a lump under the left midfoot, quite lateral, that isn't really sore but feels a bit numb.

Examination revealed tenderness under the distal plantar fascia on the right foot and the plantar calcaneus on both feet. There is a subcutaneus lump about 30mm diameter under the area of the cuboid on the left foot. Palpation makes it "feel funny"

Her foot function is not too bad; slight rearfoot varus and generally 'heavy/plodding/clumpy' gait (excuse that overly scientific description!). Mild pes planus. ROM non-weightbearing seemed pretty normal.

Recent X-rays (ordered by the GP) are reported as "Flattened plantar arch. Degenerative 2nd tarsometatarsal joint joint change with prominent dorsal osteophytes. Otherwise normal bony structures and articulations."

When I looked at the x-rays (left foot only) I was amazed to find...NO CUBOID!! The calcaneus was extra-long and articulated directly with the 5th metatarsal. There was no sign of a fusion between the cuboid and calc, just no cuboid!

I was amazed for a few reasons...
1. I've never come accross this before
2. Her foot function seemed quite good, and certainly gave no indication that she was one cuboid down.
3. The radiologist's report said "normal bony structures and articulations". I wonder what he'd say if asked specifically about the calc-cuboid joint?!

Has anyone else come accross this, or read of it in the literature?

Also, the only reason I can think of for the lump (under where the cuboid should be) is some sort of reaction to the altered mechanics/plantar pressure in that area. Fibroma/lipoma/neuroma perhaps, but is it just coincidence that it's in the area of the missing cubiod?

The GP has seen the lump and is not concerned, I wonder if it should be investigated further under ultrasound?

As my year 12 Chemistry teacher would ask "Any comments, questions, queries?"

Thanks,
Josh

 

This is a congenital synostosis of the calcaneo-cuboid joint. It is relatively rare, but I saw it once before during one of my podiatric surgery residency interviews at Kaiser Santa Clara in 1983. By the way, I missed the missing CCJ also....didn't get the residency....the rest is history.

http://www.ejbjs.org/cgi/reprint/27/4/718

http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=4020665&dopt=Abstract

 

I had a refferal for a patient with a "weight bearing Medial Malleolus" once. I got all exited thinking i was going to see some bizarre congenital deformity then found out it was just a GP getting muddled between navicular and Malleolus. :( I was really disappointed.

I don't know why but that gives me a nice warm feeling.

You seem to have done OK since then ;) .

Regards
Robert